Association between Bilateral Infarcts Pattern and Detection of Occult Atrial Fibrillation in Embolic Stroke of Undetermined Source (ESUS) Patients with Insertable Cardiac Monitor (ICM).

BACKGROUND AND AIMS: Increasingly, insertable cardiac monitors (ICM) have been used to detect Atrial Fibrillation (AF) in patients with cryptogenic stroke or embolic strokes of undetermined source (ESUS). We aim to examine the characteristics of these patients who were subsequently found to have AF. METHODS: We studied 83 consecutive patients who were comprehensively evaluated using neuroimaging and vessel imaging (computed tomography angiography, magnetic resonance angiography, or transcranial and extracranial Doppler sonography) to have met the previously established ESUS criteria. All 83 patients had ICM implanted between 2015 and 2017. All patients were followed up for at least 1 year, with a median follow-up period of 1.5 ± .5 years. We compared the baseline clinical, laboratory, echocardiographic, neuro-imaging profiles, and clinical outcomes in terms of functional recovery, recurrent stroke, and mortality in patients with and without detected AF. RESULTS: AF detection rate in this ESUS cohort was 12% over the study period. Patients with detected AF were associated with bilateral infarcts pattern at presentation (30% versus 5.5%, P = .035). Infarcts involving multiple vascular territories was not significantly associated with the detection of AF. There were no significant differences in the other clinical characteristics and outcomes between the AF group compared to the group without detected AF. Echocardiographic parameters including left ventricular ejection fraction and left atrial diameter were also not shown to be significantly different. CONCLUSION: Our study found that a neuroimaging profile of bilateral infarcts was associated with AF detection using insertable cardiac monitor in ESUS patients. Larger prospective studies are needed to validate our findings.

Derivation and Validation of a Scoring System for Intravenous Tissue Plasminogen Activator Use in Asian Patients.

BACKGROUND AND PURPOSE: As Chinese Asian populations have an increased risk of intracerebral hemorrhage (ICH) after intravenous tissue plasminogen activator (IV tPA), we aimed to design a rapid, clinically applicable risk scoring system to predict ICH and functional outcomes after IV tPA treatment in Asian ischemic stroke patients. METHODS: From January 2009 to December 2012, consecutive acute ischemic stroke patients treated with IV tPA recruited from the Stroke Registry in Chang Gung Healthcare System (SRICHS) in Taiwan and the National University Hospital of Singapore (NUHS) acute stroke database were used to create and validate a scoring system. Nomogram was created for ICH and 3-month mortality. RESULTS: In total, 932 patients were included in the study: 386 from SRICHS for the derivation of scoring system and 546 from NUHS to validate it. We used nomograms to assign weightage to the scoring system. The presence of atrial fibrillation, glucose level, and the National Institutes of Health Stroke Scale (NIHSS) score were significantly associated with the risk of ICH. Age, NIHSS score, hyperlipidemia, and the presence of post-tPA ICH were significantly associated with mortality. The areas under the curve of derivation and validation cohorts were .663 and .662 for ICH, and .808 and .790 for mortality, respectively. CONCLUSIONS: The scoring system using nomograms can provide a fast, practical, and user-friendly tool that allows physicians to predict the risk of ICH and functional outcomes with IV tPA treatment in a clinical setting.

Non-invasive intracranial pressure monitoring with transcranial Doppler in a patient with progressive cerebral venous sinus thrombosis.

In many intracranial disease states, monitoring of intracranial pressure (ICP) is essential to evaluate response to the therapeutic measures as well as estimation of prognosis. Although, direct estimation of ICP is reliable, it is invasive and not possible in all patients. Transcranial Doppler (TCD) ultrasonography is a bedside and noninvasive technique that provides reliable and real-time information about cerebral hemodynamics. We present a case of extensive and progressive cerebral venous sinus thrombosis in which TCD served as an excellent tool for monitoring ICP and the serial observations correlated closely with clinical status and ophthalmological findings.

The clinico-radiological spectrum of isolated cortical vein thrombosis.

Isolated cortical vein thrombosis (ICVT) in the absence of sinus or great venous involvement is rare. Various MRI sequences have been proposed for diagnostic accuracy, although follow-up data are limited. The optimal management strategy remains uncertain. Patients with ICVT treated between 2006 and 2008 were retrospectively studied. Diagnostic and follow-up neuroimaging were reviewed independently, and we evaluated their treatment and outcomes. Five patients (mean age 41 years; range, 25-54 years) were included. All presented with seizures. Focal neurological deficits were noted in one patient only. T2 susceptibility-weighted MRI abnormalities were observed in all patients. T2-weighted parenchymal hyperintensities involving the cortical-subcortical regions around the ICVT had completely resolved on follow-up scans. Clinical outcomes were uniformly good, despite variable treatment strategies. We observed significant, yet reversible, parenchymal T2-weighted MRI lesions in our patients with ICVT. Follow-up clinical and radiological studies demonstrate recovery independent of treatment regimes. T2-weighted MRI was found to be a useful diagnostic tool and might improve diagnostic accuracy in carefully selected patients with new-onset seizures.